Infection prevention and control practices for CPE in Ontario, Canada – are we doing enough?

We’re delighted to have this guest post from Dr Alainna Jamal (bio below)…

Hello from Canada! In this blog post, I’ll reflect on findings from a study by our group (the Toronto Invasive Bacterial Diseases Network), published in this month’s issue of Infect Control Hosp Epidemiol.

The Toronto Invasive Bacterial Diseases Network has performed population-based surveillance for CPE in south-central Ontario, Canada, since its emergence in the region in 2007. Though CPE are not yet widespread in Canada, CPE incidence has doubled every 2 years since 2007 in south-central Ontario (to ~1.3 clinical isolates per 100,000 population in 2017). We have provincial guidelines for CPE control, and to determine whether there was uptake of recommendations, we surveyed all acute care hospitals in Ontario (n=116) about their CPE prevention and control practices. One hundred and five (91%) hospitals responded, and findings most interesting to us are described below:

  1. Admission screening:

A minority (~20%) of hospitals screened patients if they had prior exposure to Canadian healthcare. This is despite at least 30% of cases in our region being associated with prior Canadian healthcare (as opposed to healthcare abroad/travel), and also despite evidence suggesting that screening patients with only a history of local healthcare is cost-effective in low prevalence settings like ours. It can be challenging to update guidelines sufficiently frequently to reflect new evidence – currently, our provincial guidelines recommend screening patients with prior healthcare abroad but not those who have only had prior Canadian healthcare.

  1. Precautions to prevent CPE transmission:

~95% of hospitals placed colonized patients on contact precautions (as per provincial recommendations), and contact precautions were never discontinued at ~50% of these hospitals. Due to insufficient evidence, our provincial guidelines do not recommend a time to discontinue precautions, highlighting the importance of improving our understanding of the natural history of CPE colonization. The ECDC highlights this challenge as well.

  1. Environmental cultures:

A minority (~20%) of hospitals reported culturing the hospital water environment for CPE. Outbreaks linked to CPE-contaminated sink drains have been reported in the literature, and ~6% of hospitals reported these types of outbreaks in this study. If only ~20% of our hospitals are looking for drain contamination, and only a third of our hospitals are following guidelines that suggest managing drains differently in rooms of patients with CPE, we may end up with a persistent CPE reservoir in our hospital water environment. What will the consequences of this be?

  1. CPE outbreaks:

Eight hospitals declared an outbreak. Only ~50 of hospitals reported that they would screen patients in an outbreak – this finding is concerning, but may be because most hospitals have yet to experience an outbreak.

Overall, there was variability in CPE prevention and control practices between hospitals. We think this is partly driven by lack of evidence surrounding best practices, but possibly also driven by hospitals not seeing a need for these programs (~65% of hospitals indicated that cost was not a limitation for their admission screening programs).

If control programs are most likely to be effective when prevalence is low and when coordinated, regional action is taken, how do we achieve a province- or country-wide approach to CPE control in Canada? Generating evidence to inform CPE guidelines is undoubtedly important and still needed, but how do we also promote broader uptake and implementation of guidelines?                                                                                                                                          

Bio:

Alainna J. Jamal is a combined MD-PhD student and Vanier Scholar at the University of Toronto in Canada. She is completing her PhD in Epidemiology, with a focus on the prevention and control of CPE. Twitter: @AlainnaJJ.

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